Get 2013authorization Request Form Sleep Study.pdf

Completing the 2013 Authorization Request Form for a sleep study can seem daunting, but this guide will help you navigate each section with confidence. By following the steps outlined, you will ensure that your form is completed accurately and submitted successfully.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member information in the designated fields. Include the patient name, address, gender, date of birth, and phone number.
3. Fill out the health plan details. Select the appropriate type of plan (HMO, PPO) and provide the group number and subscriber name.
4. Input the requesting provider information, including the subscriber number.
5. Provide details about the proposed provider and facility, including their name, address, city, state, zip code, phone number, and fax.
6. Complete the request for the sleep study by indicating if it is for suspected obstructive sleep apnea and specifying other conditions if applicable. Document height, weight, and the ICD-9 code.
7. Answer whether this is an initial request or a repeat. If it is a repeat, include the date of the last sleep study and attach the results.
8. Respond to the series of questions regarding symptoms such as witnessed apnea episodes, fitful sleep, excessive daytime fatigue, loud snoring, hypertension, abnormal ENT exam findings, and any other pertinent risk factors.
9. After filling out all required fields, review the information for accuracy.
10. Save changes to your work, then choose to download, print, or share the completed form as needed.

Ensure your sleep study request is processed by completing the form accurately online today.